Association of FXII 5’UTR 46C>T polymorphism with FXII activity and risk of thrombotic disease

Objective: Thrombotic diseases are caused by genetic and environmental factors. There are a number of well-characterized genetic defects that lead to increased risk of thrombosis. Results from previous studies have indicated that FXII is involved in the pathogenesis of thrombophilic diseases. However, the results in this regard are highly controversial. One of the most important determinants of Plasma FXII level is 46CgT polymorphism in the FXII gene. In the present study, the risk of thrombophilic diseases related to this polymorphism was investigated in a case-control study. Material and Methods: One hundred and sixty subjects were studied: 120 patients diagnosed with thrombophilia (96 venous thromboembolism, 24 arterial thrombosis), and 40 age-gender-matched controls. For each subject, FXII activity level was measured by a one-step clotting assay with FXII-deficient plasma, and 46CγT polymorphism was genotyped using a restriction fragment length polymorphism (RFLP) method. Results: In this study, the previous observation that individuals with different genotypes for the 46 CγT polymorphism show significant differences in FXII activity levels was confirmed. Most importantly, FXII activity ≤68% was associated with an increased risk of venous thrombosis with an adjusted odds ratio (OR) of 4.7 (95% confidence interval [CI]: 1.03-21.1, p=0.04). However, it was not a risk factor for arterial thrombosis with adjusted OR of 5 (95% CI: 0.91-27.1, p=0.09). In CT and TT genotype, the adjusted ORs were 2 (95% CI: 0.9-4.4, p=0.11) and 2.3 (95% CI: 0.45-11, p=0.48), respectively, for patients with venous thrombosis compared with the controls. Similarly, the adjusted ORs in arterial thrombosis were 1.2 (95% CI: 0.4-3.6, p=0.76) for CT and 1.8 (95% CI: 0.2-14.9, p=0.59) for TT genotype. Thus, we did not find any association of the mutated T allele in the heterozygous or homozygous state with an increased risk of venous or arterial thrombosis. Conclusion: Lower FXII activity is not a risk factor; rather, it simply represents a risk marker for thrombosis

Gastrointestinal bleeding in a newborn infant with congenital factor X deficiency and COVID-19—A common clinical feature between a rare disorder and a new, common infection

Dear Editors, Congenital factor X (FX) deficiency is an extremely rare, bleeding disorder with an estimated incidence of one per 1 million. Patients with severe FX deficiency (FX:C < 1%) demonstrate a wide spectrum of serious clinical presentations, including hemarthrosis, hematoma, gastrointestinal (GI) bleeding, intracranial hemorrhage (ICH), and umbilical cord bleeding.1 In fact, severe FX deficiency, with a high rate of life‐threatening bleeding, is the second‐most severe, rare coagulation factor deficiency (RCFD) after FXIII deficiency.1, 2 Although homozygotes are at risk of severe bleeding, heterozygotes usually are asymptomatic, but postsurgical bleeding or bleeding after childbirth may occur.1, 2 Other risk factors can increase the risk of bleeding in FX deficiency, and coronavirus disease 2019 (COVID‐19), a new medical challenge, could affect the patient's bleeding or thrombotic tendency.3 COVID‐19, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) presents an enormous challenge for everyone, especially for those with underlying risk factors such as cardiovascular disease, diabetes, obesity, and renal failure. Age and male sex are other risk factors.4 Limited data are available regarding the effect of COVID‐19 on patients with congenital bleeding disorders (CBDs), particularly RCFDs.5 It has been shown that hypercoagulability‐related adverse consequences are less common among patients with CBDs, at least in those with moderate‐to‐severe deficiency, but further studies, including our ongoing work on a large number of patients, are required.5 Although there are several reports of newborns among infected pregnant mothers, this is the first report of such a case in an RCFD. This case report may help medical professionals to better manage similar cases. A 19‐year‐old pregnant woman was infected with SARS‐CoV‐2 early in the 9th month of pregnancy. Reverse transcriptase‐polymerase chain reaction (RT‐PCR) confirmed the infection. The patient had been in close contact with family members with confirmed COVID‐19. The patient had cough and fever. Due to the mild presentation, she was given Azithromycin and advised to isolate herself at home. The symptoms resolved within 14 days. At end of her 9th month, three days prior to the planned cesarean section, she was rechecked for SARS‐CoV‐2 infection; her RT‐PCR was negative. She successfully underwent cesarean section without complications and delivered a healthy full‐term baby. Therefore, mother and newborn discharged the following morning. In the evening, the baby experienced bloody vomiting and was hospitalized for further assessment, which showed GI bleeding. At admission, laboratory tests showed a positive C‐reactive protein (CRP) (qualitative), a low hemoglobin level, and prolonged prothrombin time (PT), and activated partial thromboplastin time (APTT) (Table 1). He was hospitalized in the neonate intensive care unit (NICU) for 10 days. Due to the risk of SARS‐CoV‐2 infection, on the third day after admission he was tested by RT‐PCR, which was positive. The neonate received 30 mL frozen plasma (FFP) six times over 10 days, which resolved the GI bleeding. Tranexamic acid (TXA) was administered at a dose of 10 mg/kg every 8 hours. Due to lack of COVID‐19 symptoms, he did not receive any special treatment for the disorder. After 10‐day hospitalization in the NICU, the neonate was sent to an isolation room for 5 days, during which his condition stabilized, after which he was discharged in stable condition. He has had no complications during the past two months after discharge. Since the child's father and two other first‐degree family members have severe FX deficiency, and the parents of the baby are closely related, the mother and the baby were checked for FX deficiency. Routine coagulation tests, and FX:C assay performed by STA Compact automatic coagulometer (Stago, Paris, France), revealed a severe deficiency in the baby, and a mild deficiency, compatible with heterozygote FX deficiency, in the mother (Table 1). Table 1. Laboratory characteristics of mother and baby with factor X deficiency and COVID‐19 Test Proband (2nd day after birth) Proband (7th day after birth) Proband (2 months after hospital discharge) Mother (about 3 1/2 months after SARS‐CoV‐2 infection) WBC × 109/L 14.2 (8‐24)b 9.43 (5‐21) 10.79 (6‐18) 8.7 (3.6‐10.6) RBC × 109/L 2.5 (4.36‐5.96) 2.78 (4.2‐5.8) 3.50 (3.4‐5) 4.41 (3.8‐5.2) Hb (g/dL) 8.2 (16.4‐20.8) 9.2 (15.2‐20.4) 10.2 (10.6‐16.4) 13.6 (12‐15) HCT (%) 24.6 (48‐68) 27 (50‐64) 29.2 (32‐50) 41.4 (35‐49) Lymphocyte × 109/L 6.4 (1.3‐11) 4.3 (1.2‐11.3) 8.21 (2.5‐13) 2.22 (1‐3.2) Neutrophil × 109/L 4.9 (2.6‐17) 2.9 (1.5‐12.6) 1.85 (1.2‐8.1) 5.75 (1.7‐7.5) Platelet × 109/L 370 (150‐450) 331 (150‐450) 334 (150‐450) 276 (150‐450) PT (sec) >60 (PTC: 12.6) 90 (PTC: 12.6) >60 (PTC: 10) 13 (PTC: 10) APTT (sec) >120 (APTTC: 31) 100 (APTTC: 30) >120 (APTTC: 32) 37 (APTTC: 32) CRP (Quantitative) Trace Negative NC NC FX:C level NC NC <1% (50%‐150%) 40% (50%‐150%) Abbreviations: APTT, activated partial thromboplastin time; APTTC, APTT control; CRP, C‐reactive protein; Hb, hemoglobin; HCT, hematocrit; NC, Not checked; PT, prothrombin time; PTC, PT control; RBC, red blood cell; WBC, white blood cell. a Hematological test normal ranges are extracted from Rodak's Hematology: Clinical Principles and Applications, 5th Ed (2016). b Normal values are placed in parentheses. COVID‐19 is an emerging medical challenge that can present more difficulties for those with special conditions, such as pregnant women and newborns. Due to alterations in cellular immunity, pregnant women are more prone to infection by intracellular pathogens like viruses.6 The fetus is also highly susceptible to infection due to immaturity of the immune system.7 Furthermore, the mother's (heterozygote) congenital coagulopathy and that of her newborn (homozygote) were additional potential risk factors, because a disrupted coagulation system is a prominent feature of SARS‐CoV‐2 infection.8 To date, FX deficiency in a newborn has not been cited anywhere as a special condition requiring close attention in the case of SARS‐CoV‐2 infection. According to the few reports to date, SARS‐CoV‐2 infection is a risk factor for severe maternal morbidity. It is worth noting that most of those mothers were discharged without complications.9 From a clinical aspect, fever was the most common symptom (68%) at the time of admission.9 This was also observed in the affected woman of this study. SARS‐CoV‐2 infection can even affect the type of delivery. A systematic review of these women showed that about 92% of deliveries were by cesarean section, less than 10% being the usual vaginal delivery (7 of 85). Fetal distress was mentioned as the most common indication for cesarean section. Our patient underwent a planned cesarean section, due to her previous history. The delivery itself was uneventful, and a healthy baby was delivered, while among other reported cases, a number of complications have been noted.9 As with most other reports, the infant did not have any symptoms at the time of delivery and was discharged the day after birth.9 In a case series of 10 patients, various first clinical presentations were observed, including shortness of breath (n = 6), fever (n = 2), vomiting (n = 1), and rapid heart rate (n = 1).10 In the case at hand, bloody vomiting was the first clinical presentation. In the same case series, one died due to refractory shock, multiple organ failure (MOF), and disseminated intravascular coagulation (DIC). Another patient with severe presentation was managed by intravenous infusions of gamma globulin, platelets, and plasma, which was suggestive of the effectiveness of gamma globulin in severe cases. The author recommended early use of intravenous gamma globulin for passive immunization.10 GI bleeding in our case was successfully managed by administration of FFP and TXA. In addition to thrombotic complication, bleeding is not infrequent in patients affected by COVID‐19, with GI bleeding seemingly the most common hemorrhagic manifestation among adults. GI bleeding, with a frequency of 40%, was observed among neonates from affected mothers.3 On the other hand, GI bleeding is also a relatively common presentation among severely FX deficient patients.1, 2 In fact, GI bleeding can occur in children with severe FX deficiency within the first months of life. It seems that such patients are prone to experience severe bleeding, such as ICH, later in life, in the absence of an appropriate therapeutic strategy, most likely preventative regular secondary prophylaxis.1, 2 In one study of 102 patients with congenital FX deficiency, GI bleeding has been reported in 12% of symptomatic cases.1 In this case, with GI bleeding being a common presentation of SARS‐CoV‐2 infection and congenital FX deficiency, it cannot definitively be attributed to one or the other. Close monitoring of such cases is necessary to decrease related adverse consequences. Although it seems that COVID‐19 is less severe in adults with CBDs, it is a less‐known issue among children and newborns with CBDs. Further reports and studies could provide clarity. Due to their severe bleeding tendency, close monitoring of patients with severe congenital FX deficiency is mandatory, even without potential SARS‐CoV‐2 infection. And close monitoring of neonates with infected mothers is mandatory to prevent severe consequences. Patients with concomitant infection with SARS‐CoV‐2 require even more rigorous preventative and supportive care. ACKNOWLEDGEMENTS We highly appreciate Daisy Morant's valuable aid in improving the English Language of this manuscript. The study was supported and approved by Shahid Beheshti University of Medical Sciences. CONFLICT OF INTEREST The authors have no competing interests. AUTHOR CONTRIBUTIONS A. Dorgalaleh designed the work, performed laboratory analysis, and wrote the manuscript. F Ghazizadeh, M. Baghaipour, A. Dabbagh, Gh. Bahoush, and N Baghaipour performed clinical studies. Sh. Tabibian, M. Jazebi, N. Baghaipour, M. Bahraini, A. Fazeli, and F. Yousefi performed laboratory analysis. All the authors approved the submission

Development of composite membranes for the separation of miscible liquids by applying pervaporation technique to pressurised feed solutions

For the first time pervaporation separation of miscible liquids have been investigated with three and five layered composite membranes with layers of Natural Rubber Latex (NRL) and layers of hydrophilic, hydrophobic or organophilic polymers which are placed on top of each other. NRL was used in all different types of the membranes, mixed with hydrophilic polymers in blend membranes and in a layer shape in the three or five layered composite membranes. Methyl Cellulose (MC), Carboxymethyl Cellulose (CMC) and Hydroxypropyl Methyl Cellulose (HMC) were used as hydrophilic polymers to increase the water selectivity of the membrane and in contrast, Ultra-High Molecular Weight Polyethylene (UHMWPE) and Polydimethylsilane were used to increase organic component selectivity in the membranes. These membranes were used to separate miscible liquid solutions including ethanolwater, propanol 2-water and acetone-waterT. he composition of organic componenti n the feed was varied within the range of 20 to 90% w/w. The temperature of operation was kept constant to 20'C. Scanning Electron Microscope (SEM) has been used to study the distribution of polymers within the membranes. Morphological features of the cross section and top surface of the membranes have been used to develop a probable mechanism of water or organic component transfer through the membrane. For the first time ever, DMTA technique has been used to identify the type of membranes which can be used to increase the water selectivity (by studying the changes in the glass transition temperatureo f the NRL, blend and compositem embranes). Both SEM and DMTA techniques have proved that the presence of hydrophilic polymers as in layer forms in the three or five layered composite membranes was the reason for good distribution of polymers throughout the membrane. It has been established that a very strong correlation exists between a good distribution of the polymer bridged clusters of rubber particles within the membrane and the maximum increase in water selectivity. The influence of using different types of alcohols (ethanol, propanol 2 and acetone) on the pervaporation separation performance of the membranes has been thoroughly examined. Using ethanol, having the lowest molecular weight as compared with the other solutions, leads to the best performance in pervaporation separation

Development of composite membranes for the separation of miscible liquids by applying pervaporation technique to pressurised feed solutions

For the first time pervaporation separation of miscible liquids have been investigated with three and five layered composite membranes with layers of Natural Rubber Latex (NRL) and layers of hydrophilic, hydrophobic or organophilic polymers which are placed on top of each other. NRL was used in all different types of the membranes, mixed with hydrophilic polymers in blend membranes and in a layer shape in the three or five layered composite membranes. Methyl Cellulose (MC), Carboxymethyl Cellulose (CMC) and Hydroxypropyl Methyl Cellulose (HMC) were used as hydrophilic polymers to increase the water selectivity of the membrane and in contrast, Ultra-High Molecular Weight Polyethylene (UHMWPE) and Polydimethylsilane were used to increase organic component selectivity in the membranes. These membranes were used to separate miscible liquid solutions including ethanolwater, propanol 2-water and acetone-waterT. he composition of organic componenti n the feed was varied within the range of 20 to 90% w/w. The temperature of operation was kept constant to 20'C. Scanning Electron Microscope (SEM) has been used to study the distribution of polymers within the membranes. Morphological features of the cross section and top surface of the membranes have been used to develop a probable mechanism of water or organic component transfer through the membrane. For the first time ever, DMTA technique has been used to identify the type of membranes which can be used to increase the water selectivity (by studying the changes in the glass transition temperatureo f the NRL, blend and compositem embranes). Both SEM and DMTA techniques have proved that the presence of hydrophilic polymers as in layer forms in the three or five layered composite membranes was the reason for good distribution of polymers throughout the membrane. It has been established that a very strong correlation exists between a good distribution of the polymer bridged clusters of rubber particles within the membrane and the maximum increase in water selectivity. The influence of using different types of alcohols (ethanol, propanol 2 and acetone) on the pervaporation separation performance of the membranes has been thoroughly examined. Using ethanol, having the lowest molecular weight as compared with the other solutions, leads to the best performance in pervaporation separation.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Survey of the relationship between of thrombophilic factors and the rate and severity of bleeding in patients with severe hemophilia A

Introduction: Hemophilia is the most common disorder of deficiencies in thrombotic factors. Inmost patients, severities of symptoms are in proportion of the seriousness of deficiency in thethrombotic factors. But in some patients with severe hemophilia, having less than 1% in factor level;the clinical symptoms are lower and slighter than the other hemophilic patients. Even in some cases,thrombotic events in the severe hemophilic patients have been accrued. The underlying causes of thesefindings are unknown. The aims of this study were to determine the role of some factors and also thetype of genetic mutation of these factors in the rate and severity of bleeding and also the symptoms ofthe severe hemophilic patients.Materials & Methods: Sixty hemophilia A patients (FVIII<1%) with having records inHemophilic Patients Center were divided on the basis of the received factor rate items per year,bleeding score, orthopedic score and radiologic score, in three groups with mild, moderate and severclinical presentations (each group with 20 patients). And then the mutation tests in the gene of LeidenV factor, PG20210A, MTHFR, level of thrombotic factors (II, V, VII, VIII, IX, X, XI, XII, XIII, andFibrinogen), Protein C, S, Antithrombine III, Phospholipid Ab and Hemosisteine and number ofplatelets were performed. Data using the χ2, Fischer, ANOVA and Tukey test and SPSS-14 wereanalyzed.Results: Of the studied factors, the differences among 3 groups from view point of daily activity(P<0.002), antithrombine III (P<0.013), number of platelets (P<0.007), protein C (P<0.013) and levelof factor XII (P<0.01) was significant. No significant differences were found in three groups in othertested factorsConclusion: In this study, there were significant differences only in the daily activity,antithrombine III, number of platelets, protein C and level of factor XII. Thus, further studies arerequired to determine the role of other factors that may contribute to differences in the clinicalpresentations of the severe hemophilic patients

Correlation of thrombotic factor with bleeding severity in patient’s with factor XI deficiency

Introduction: Factor XI is a glycoprotein that important role in blood coagulation. The aim of thisstudy is determine correlation of thrombotic factor and bleeding severity with factor XI deficiency.Materials and Methods: 24 patients with factor XI deficiency were included in this study. Followingphysical examination and interview, a questionnaire was filled for all the patients. A blood sample wascollected for measurement of coagulation factors (II, V, VII, and VIII, IX, X, XI, XII, and XIII),fibrinogen, protein C, protein S, antithrombin III, PG20210A, factor V Leiden, MTHFR gene andHomocystein.Results: 54.2% and 45.8% of patients were male and female, respectively. Mean (±SD) age of patientswas 27.2±13.6 (3-49) years. 45.8%, 29.2%, 25% of the patients showed mild, moderate and severebleeding, respectively. Although, a significant positive correlation was observed between factor V andbleeding severity (P=0.033, r =0.491), there was no correlation between bleeding severity and otherthrombotic factors.Conclusion: The findings showed that a positive correlation between factor XI deficiency and factorV. We need more studies as multicenter studies to detecting the relation of other thrombotic factors withbleeding severity in patients with factor XI deficiency